Coming Out Trans:
Questions of Identity for Therapists Working with Transgendered Individuals

(Trans Identity from the Queer Perspective)

[An earlier version of this paper was originally delivered as a presentation at the In the Family conference “Fostering Therapies of Resilience,” San Francisco, CA, June 2001. At that time I was a member of the Ethics Committee of the Harry Benjamin International Gender Dysphoria Association (now the World Professional Association for Transgender Health), past-president of the San Francisco Chapter of the Society for the Scientific Study of Sexuality, a member of the International Foundation for Gender Education, FTM International, and TGSF (Transgender San Francisco), and had been, since 1989, a participant in Bay Area Gender Associates (BAGA), the longest-running therapists’ peer consultation group in the world devoted exclusively to transgender identity issues. I thank my BAGA colleagues – Rebecca Auge, Ph.D.; Koen Baum, MFT; Lin Fraser, Ed.D.; Kim Hraca, MFT; Dan Karasic, M.D.; Luanna Rodgers, MFT; and Anne Vitale, Ph.D. – for their thoughtful readings of and responses to this paper in its penultimate draft.]

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What is gender? I believe it is becoming increasingly clear … that … gender is considerably less fixed than we have been led to believe and that one’s sex has less to do with one’s wholeness than one’s individuation. So simple is this idea that I think it is easy to underestimate the momentous implications such a view has for civilization as we know it…. Ours is a culture in which the gender dichotomy has been made so central to the definition of what it means to be human that any change reverberates deeply and terrifyingly in the souls of even those who ardently wish for movement.
-- Robert Hopcke, Persona: Where Sacred Meets Profane

1. QUEERER THAN THOU

A gym-toned, bearded man and a voluptuous, large-breasted woman were walking down Castro Street a few years ago, in the heart of San Francisco’s gay mecca, and as they passed a local coffee place they were hissed for being breeders. The man had once been an extremely well-known member of San Francisco’s leatherdyke community, and the woman had been a recognizable gay male resident of this very neighborhood for years. At such a moment that altogether transcended degrees of queerness, what could they do but laugh? At that moment, what could they have said about the ways gender identity, gender roles, and sexual orientation intersect? How can we talk about identity in this context? What is a trans identity from the queer perspective?

The premise of this paper is that, at least in the absence of a known transgendered therapist or specialist, you and you and you and I – therapists known to be LGB – are often the referrals of choice among straight doctors and therapists for their transgendered clients, simply because straight people often presume similarities between “transgressive” gender identities and “transgressive” sexual orientations.

We and our transgendered clients may make the same assumptions, and in fact there are many reasons to include “T” along with GL and B in the headlines, banners, parades, and events that more and more bind a very broad coalition into a single community of people. What makes our sometimes disparate groups one community can be understood most simply by the need every individual in those groups has to take at least one look at his or her own identity, exactly terms of sex and gender, that the main body of straight, heterosexual, vanilla, non-queer folk do not have to do. Even though some straights most certainly do make such an examination, they don’t have to: they can get along in their lives, in their relationships, and in society without ever attending to that aspect of themselves; and so I use that necessity to define the concept of queer, and it is what, for me, lumps T in together with LGB and a few other fellow travelers, such as people in the leather, or BDSM, communities.

But being transgendered and being G, L, or B are also not alike in many ways, and in those ways the experience of coming out with a variant gender identity, including coming to terms with a gender-variant life, is not like the experience of other comings out.

Certainly the finest psycho-political rhetoric says each person is unique, and certainly we shrinks not only believe it, but also have laboratory evidence that it is true, though admittedly our samples are small, non-random, uncontrolled, and skewed. Yet – considering the way our culture views human identity altogether – if we go beyond our presumptions, then in those areas where we truly do stand apart from the mainstream by reason of who and what we are, queer therapists have a unique opportunity to serve queer others who are in the process of coming to terms with their own identities. In order to do that with gender-variant people it helps to learn what the trans experience is like, in some measure, so we can learn what our trans clients need, and respond with genuine empathy to them and to all people working their gender identities.

2. LEARNING TO BE MYSELF

I remember attending a lecture on queer art in about 1990, where the photographer Mark I. Chester started his presentation by lifting his shirt and dropping his pants, displaying his ample tattoos and piercings, among other things, in order to show he had nothing to hide.

My version of truth in advertising is more academic: I refer you to my own essay on Multiple Personality Order (MPO) (Henkin, 1997), which describes one paradigm for understanding cross-gendered experience. In that essay I assume dissociation to be a continuum that ranges from Dissociative Identity Disorder, or what used to be called Multiple Personality Disorder, to the sort of dissociative process with which we are all familiar – dreaming, daydreaming, becoming so involved with work or with reading a book or watching a film that we “lose” ourselves. In that context I examine the concept of the Inner Child and other alters as personifications of our variable states of mind: as fairly common dissociative states that can, for some people, include cross-gendered experience. As I did in that essay, I am writing this one not only as a clinician, rather than as a scholar or a researcher, but also as someone who has done my own share of gender exploration on the road to concluding that I am not transgendered. In some measure, then, I’m talking from both – or at least from two – sides of my experience.

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In the mid-1980s I was working in a community mental health facility in another city. One morning, on my watch, I received information that two of the residents had slept together in the house the previous night, which was a cardinal infraction in that program whose mandated consequence was immediate discharge. But I knew one of the women, who was so familiar with our facility that some of the staff regarded her more as a pal than a client. I knew she could act out, but I had never seen her behave so, well, so stupidly, without some compelling reason.

I called both women into the office, ascertained that the accusation was correct, and asked the reason for their behavior. Somewhat sheepishly, both women told me they wanted to know what “it” was like. “It?” I knew the first woman had slept with plenty of other women: she was not a virgin. But the second woman was new to the facility and we had barely met. I asked what “it” was.

“It” turned out to be that the second woman was a pre-op MTF (male-to-female) transsexual, and actually had her surgery date set for just a few days after her planned discharge from our facility. She had never slept with a woman before, and the first woman had never slept with a transsexual woman. The temptation of the unknown had been too much for them to resist.

With the ball was in my court I elected to ground both women for the weekend – a gentle slap on the wrist at the time and under the circumstances – rather than toss them from the house. An hour later I had to defend my decision in staff meeting. Several of the women on staff reconciled themselves to my leniency because they were countertransferentially fond of woman number one and therefore felt themselves morally obligated to tolerate woman number two, even though they thought that since she was, well, odd, and since she was a stranger to our house anyway, she had probably been the seductress and should really be dealt with more severely. But once her gender status was made clear, not a single other man on staff could find his way to agreeing to keep woman number two, and several were vehement – “panicked” was the word that came to my mind at the time – about getting her out before their shifts commenced.

Eventually my chosen punishments prevailed and both women stayed, but only on condition that I become the primary in-house counselor for woman number two; and since I did not seem to have the same highly anxious response to her that the other men on staff felt, there began my education in transgender identity. My client talked to me about her own experience, loaned me what was then the very recent video, What Sex Am I?, provided me with pamphlets about transgender issues, and gave me the name of her therapist in San Francisco, whom I called and who spent a somewhat hectic hour talking to me in his Union Street office.

Her therapist, the late Paul Walker, was among the founders of the Harry Benjamin International Gender Dysphoria Association (HBIGDA), and was its first president. In addition to seeing clients, he was running the Janus Information Facility when I met him, educating people to the nature of transgender identity issues. I read the Janus pamphlets and much else I found on the topic, and while I cannot say I was remotely “prepared,” I was at least not wholly ignorant when a heterosexual couple entered my private practice, the male of whom was a female-to-male (FTM) transsexual.

Some time thereafter I tried on a pair of the high heeled shoes my partner in process, Sybil Holiday, kept for her cross-dressing clients, and experienced a remarkable transformation in myself. While I was “Bill” I found the shoes alien, and walking awkward. In every way I was simply uncomfortable wearing them. But then I felt another aspect of myself rise up in my body awareness like a co-conscious personality, and she – I can only describe the feeling of this persona’s presence as female, though I recognize I have never been a woman and in that sense I could not possibly know what I’m talking about – she had a completely different response: she loved the shoes. She liked what they looked like, she liked seeing them on “her” feet, and spontaneously, effortlessly, she began to walk in them. This experience was only remotely erotic, in the way that doing anything vaguely naughty can titillate the nerves. Far more, it was aesthetic, serene, and satisfying for an aspect of myself I had not met before at any conscious level. The feeling “fit” her, as did the shoes.

A month or so later The International Foundation for Gender Education (IFGE) held its annual conference in San Francisco and I attended its professional track, but it was Juliette – that femme part of me that had liked the shoes – who attended the awards banquet. I joined ETVC, the Bay Area’s MTF cross-gender group that is now called TGSF, and attended the first of numerous meetings. While taking the San Francisco Sex Information (SFSI) training I also met Lou Sullivan, founder of what is now FTM International, the largest female-to-male cross-gender group in the world, and partly due to the courage he displayed when discussing his own relationship with gender in front of 60 strangers, I began to explore what gender meant to me personally.

The personal and the professional overlapped for awhile. In 1989 I became part of the longest-standing transgender identity clinical consultation group in the world, now known as the Bay Area Gender Associates (BAGA). For years, alone or with Sybil, I made presentations at other IFGE conferences and elsewhere, and was, with her, a guest of honor at Fantasia Fair in 1991 – though it was always Juliette who went to the parties. In 1995 I spoke at the First FTM Conference of the Americas, and at the First International Congress on Cross‑Dressing, Gender, and Sex, for which I developed the presentation that became my first essay on multiple personality order. About that same time I began a several-years’-long stint as Clinical Supervisor for the Tenderloin AIDS Resource Center, working specifically with the counselors of dual- and triple-diagnosis transgendered people. Alone or with colleagues I made presentations about transgender identity issues for HBIGDA, the Society for the Scientific Study of Sexuality (SSSS), and other groups, and for several years I co-taught the doctoral level course in transgender identity issues at the California School of Professional Psychology, now part of Alliant University.

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I don’t pretend to be absolutely current in this continually-changing field, and I expect people to disagree with some things I say: Among a professional audience I am certain that the extent of our experience, as well as our levels of expertise with our subject, are tremendously varied. In any case, I can only speak from my experience. But I hope that where we differ or even disagree we can use our differences and disagreements as starting points for discussions here and elsewhere, rather than as cudgels in what has too often been a divisive, somewhat internecine war in the transgender trenches.

Also, of course, exposure inures. I live and work in San Francisco, which really is different from other places. This is not just a gay mecca: despite our obligatory resident yahoos 1 and our share of bashings both physical and political, it is a city where Out-siders seem to feel relatively comfortable and safe. Home of several third-gender groups, it is a city where the very progressive gay leader Tom Ammiano was president of the Board of Supervisors and made a serious run for mayor, where gay, lesbian, and bisexual people often hold important political offices, and where the City and County government covers a substantial portion of expenses for those of its transgendered employees who choose to transition. With occasional reactionary hiccups San Francisco has been, since its Gold Rush founding, a city where individual and social explorations are not hidden, including those around sex and gender, right up to the cutting edge. Consequently, as numerous transpeople have noted to me, this is the easiest place in the country to transition, but the hardest in which to pass.

3. IN RE: DIFFERENCES

Transgressions

Coming out trans is like coming out gay, lesbian, or bisexual chiefly because the person who does so announces him- or herself to be somehow “different” about sexual identity in a society that does not generally distinguish sex from gender, that is confused about the similarities and differences between orientation and identity, that exhibits conspicuous agitation around sexual matters altogether, and that rather frantically encourages its constituents to proclaim themselves “normal”: a concept that is terrifically vague outside statistical matters but that in our culture usually means, in particular, “not-different.”

Just as certain heterosexual men seem to panic behind their belief that any gay or bi male wants to fuck them as well as their brothers, sons, and uncles, even if those particular men hold no real interest whatsoever for the gay or bi man, so certain men of all orientations seem to have an unspoken and maybe equally unrecognized belief that if some other male-bodied person wants to cut off his penis he poses some sort of threat to theirs. I suspect the first fear incites gay bashings, as in a similar way the second leads to the trans bashings that researchers say now result in more than one death per month in this country.

These fears and their consequences are related. Numerous writers have pointed out that a basher’s fears are not inflamed by the fact that a man is gay or bi, but by his culturally feminine – his gender transgressive – behaviors. According to Riki Anne Wilchins, Executive Director of GenderPAC, her organization’s National Survey of TransViolence reveals “that the most common epithet used when [transpeople] are bashed is ‘faggot.’ Transpeople are targeted because of the perception that we are gay. And gays are often picked out because they are ‘visibly queer,’ that is, because they are gender-different.” (Wilchins, 1999).

Wilchins does not suggest that transpeople would not be bashed just for being trans, but that popular confusion paints both transwomen and gay men with a single brush because of stereotypically perceived behavior and appearance. Certainly, strangers harass leathermen, peace officers, and otherwise “manly” gay men far less than they do, say, the sweater queens of old, or than fey men of any actual orientation. Whether they mean to or not, those manly men “pass” in that they are not gender-transgressive, whatever their orientations may be.

If, in large measure, we are a society that equates gender identity with sexual orientation, we are also a society that doesn’t believe gay (and hence, trans) people are quite as human as heterosexual people; we are also still a society that doesn’t believe women are quite as human as men, so coming out issues that include gender transgression affect FTM transpeople as well those who are MTF.

With lesbian women, as with gay men – some media stars excepted – it is usually not so much a question of whom a person sleeps with, but her appearance and comportment as gender-different that first earn her discriminatory enmity. While straights do not generally distinguish lipstick lesbians from other femmes, the same fear of gender transgressive behavior that leads to violence against effeminate men also leads to violence against those females who appear culturally masculine, whether they are passing women or simply butch, as well as to transsexual murders such as Brandon Teena’s.

It seems to me that coming out with any apparent sex- or gender-transgressive behavior excites fears and antagonisms among people who feel their own values are being transgressed; and, to the extent that they identify with those values, who feel their very selves are being transgressed as well. When someone is gay, lesbian, or bisexual, the person’s transgressive behaviors may be visible or invisible and may be public or private, but appearance and behaviors in themselves do not necessarily distinguish that person from others, either in his or her own eyes or in the eyes of most other people. But when people’s transgressions affect their identity, as is always the case when someone comes out trans, their transgressions are almost inevitably public, and their virtually obligatory visibility always has repercussions.

If you think back to the children you knew and played with in your very earliest memories, you may no longer remember their names, you probably no longer remember their faces, you don’t remember their homes or their parents or siblings or pets, and unless you were at least three or four or five in your recollections you probably don’t even remember the games you played; but almost certainly you remember whether a friend was a boy or a girl, and this regardless of your childhood sexual feelings toward that playmate.

Now, once you did have sexual feelings for some of your playmates, and once you recognized those feelings were for your same-sex playmates, you probably learned pretty quickly that you had a problem, and you were taught just about as quickly that the problem belonged to you, not to your friends, family, or society. That was when you started to deal with coming out in terms of your sexual or gender identity.

Brian McNaught is an educator, corporate consultant, host of the weekly radio program On Being Gay, and author of On Being Gay, Now That I’m Out What Do I Do?, Understanding Gay Issues in the Workplace, and other books. He works largely with heterosexual audiences to promote understandings across the orientation gap, and in some of his workshops he poses an awkward situation for his audience. If you are a black kid on a white American playground and your playmates tease you and beat you up and tell you you’re no good, at least at the end of the day you can go home to parents who can hold you and say, I know, Darling: I understand. If you’re a Jewish or a Muslim or a Buddhist kid on a Christian American playground and your playmates tease you and beat you up and tell you you’re no good, at least at the end of the day you can go home to parents who can hold you and say, I know, Darling: I understand. If you’re a kid of almost any kind of minority at all, at least at the end of the day you can go home to parents who share your experience, and so can hold you and say, I know, Darling: I understand, and you can believe them and feel some little comfort that you are not alone: that a most important Someone understands you, and you have some hope and maybe even protection in the world.

But if you’re a gay or a lesbian child, McNaught points out, by the time you’re old enough to identify your feelings as being something more than childhood play, you are also experienced enough to know that you can’t tell your parents about them, because you know that they already agree with everyone else: you’re no good just because of who you are, and so you have a secret that you can’t tell anyone, and you grow up with that secret, knowing you are bad, wrong, sick, sinful, disgusting, and/or doomed to be cast out by anyone who learns it.

For a long time you probably hide your secret from anyone you can. You hide it from your family, of course, and you hide it from your friends. Perhaps you even hide your secret from yourself, so it’s no wonder gay – and bi – teens have suicide and self-harm rates conspicuously higher than those of straight teens (Gibson, 1989). 2 But however much you may come to see yourself as undesirable through your society’s or even your family’s eyes, at least no one is telling you that you aren’t who you know yourself to be.

If you’re transgendered, on the other hand, the secret you have that you can’t tell anyone is even more overwhelming than if you’re gay, because as soon as you say “I’m not a girl” or “I’m not a boy,” people point to your body, sometimes literally, and tell you you’re wrong about your very own identity. In the face of your still relatively innocent, trusting, and unencumbered awareness, the people you must trust and upon whom you must rely tell you that you are not who you know yourself to be. Especially when they derive from the mostly adult world of appearances, these assertions establish an element of identity conflict in the trans child unlike any other developmental identity conflict we know. 3 That is why coming out trans is not like coming out gay, lesbian, or bisexual. Where sex is concerned, including orientation, a person’s value may be questioned and demeaned, but where gender is concerned the person’s identity itself is indicted, and so it’s no wonder transgendered people have a suicide rate even higher than that of the gay population. 4

Even though some aging research indicates that most trans-identified children really grow up to be gay, not trans, 5 I am using the dilemma of coming out trans in childhood as illustrative because that is the easiest way to see how identity problems arise in a trans context. In a similar fashion I occasionally speak about the complex issues of transgender identity as if they were all subsumed under transsexualism, because the underlying issues stand out there most broadly.

But just as most people who question, explore, or confront transgender identity issues are not transsexual, so, clearly, there are many people who do not come out either to themselves or to others until they are adults, and some may not even be transgendered till then – although it is not at all clear to me whether some people in this position merely tried so hard to be the gender they were not that they hid it even from themselves for many years. Being transsexual is a very hard life road for most people.

Yet, while the dilemma is not as severe in adulthood when one’s ostensible power in the world is equal to that of other people’s, the issues that underlie it are the same as they are in childhood. Even in adulthood – perhaps especially in adulthood, when we are all supposed to “know” better – the relation between transgressive orientations and transgressive identities remains as confusing for most people as do the distinctions between sex and gender. This confusion is what Riki Anne Wilchins observed leads bashers to call transwomen “faggots”; it is probably what underlies the academic and clinical distinctions between sexual orientation and gender identity; and it is why we have not – yet – heard much discussion about sexual identity or gender orientation.

Until very, very recently there was no trans community; until very recently, there was effectively no explicitly trans life at all, even for people we would, today, identify as trans. And even today, even in San Francisco, and even with the world-wide resources of the web, you usually have to intend to find your way to transworld. So people looking for the life where they can fit, people seeking to learn where they belong who are not straight, heterosexual, vanilla, non-queer, often come first to the most obvious, most likely quarters.

That quest is one reason that in the course of trying to find themselves, trying to find out who they are and what the nature of their transgressions might be, many transgendered people pass through the gay communities on their ways to self-recognition – although some transpeople, like the bearded man I mentioned at the beginning of this paper, do not pass through, but become or remain gay in their new bodies. Also, harking back to my premise, it is one reason that therapists who are known to be LGB are often the referrals of choice among straight doctors, therapists, and others for transgendered clients.

Typologies

There are several theoretical typologies in the clinical and research literature that envision different spectrums for understanding transgendered status, behavior, and experience, including Harry Benjamin’s, which was the first, and Richard Docter’s, which in some ways commented on Benjamin’s 25 years later. Many clinicians end up with versions of their own, based on observations they make in their clinical practices, that seek to identify the actual range of transgendered presentations they work with. I invite you to do the same in light of your actual practice. For certainly, apart from theory and philosophy, and even apart from research, it is our actual clients in our actual practices and in their actual lives who matter to us as clinicians.

Rather than parse other people’s versions of the way things ought to be, then; and recognizing, as I said earlier, that as a therapist I necessarily see a non-random, uncontrolled, and extremely skewed population even among those people who are dealing with transgender concerns, I want to speak a bit about issues I have seen in my clinical work with a variety of transgendered people, particularly with reference to coming out trans from a queer perspective.

In the past few years my practice has included:

lesbian women with or without female partners coming out as heterosexual men;

heterosexual men coming out lesbian, including some who are virulently misandrist;

heterosexaul men coming out lesbian with other transwomen;

bi men coming out as bi women;

heterosexual male crossdressers “becoming” “lesbian” in their sex and social play with heterosexual women;

gay males crossdressing both as drag and for gender expression;

bi and nominally heterosexual men, women, and couples in the BDSM communities whose orientation to sex-role reversal – fem-dom / male-sub sex, as well as social roles – sometimes partakes of something very like cross-gendered sexual identity;

“gay men” coming out as heterosexual women.

This last category deserves some special attention because it is comprised of the male-bodied people Harry Benjamin identified as “true” transsexuals of the “high intensity” type for whom transition is both “urgently requested” and “indicated.” Relative to the rest of my transgender practice and experience this has been a small enough component to put in perspective the academic literature that claims, as the Diagnostic and Statistical Manualof Mental Disorders has repeatedly done, a ratio of 1:30,000 morphological males and 1:100,000 morphological females in the American population who are sufficiently gender dysphoric to seek what is still called sex reassignment surgery (SRS).

If the research literature is correct, statistically there should only be three or four FTM transsexuals and ten or a dozen MTFs in San Francisco, a city of fewer than ¾ million people. Even considering our welcoming attitude, which attracts outsiders from elsewhere and likely makes our numbers somewhat greater than they would be otherwise, that means I must have seen every transsexual in this city – many times over. But in that case these statistics do not address clients in the substantial practices of my seven BAGA colleagues, the half-dozen locally licensed therapists I know personally who see transgendered clients and are not part of our consultation group, and those I do not know but who must exist. Besides, I have known numerous transsexuals in town who have never seen any of us professionally.

Here’s the problem: when I say that Benjamin’s Type Six “true” transsexuals have lived as “gay men” until they transition and come out as heterosexual women, I am being hobbled by the circumstance of language and labels. These people have actually never been gay men. They have always felt female, and at least in a psychological sense they have always been female. Whether they have been extremely sexual or largely asexual in their feelings and behaviors, or anywhere in between, they have found no appropriate fit in our society. They may have tried living and being sexual in the gay or bi community, and may even have been notable femmes and drag or camp performers, but that solution doesn’t work for them because they are attracted to heterosexual men as heterosexual women.

Christine Jorgensen is the classic example of Benjamin’s Type Six “true” transsexual, and she makes the statistics sound reasonable: it would not surprise me to learn that there really are only a dozen or two such people in San Francisco: their FTM counterparts would probably be transmen such as Dr. Michael Dillon, whose surgery in England with Sir Harold Gillies preceded Christine Jorgensen’s by a half-dozen years; transmen who lived without the benefit of hormones or surgery, such as jazz great Billy Tipton; and perhaps also passing women such as Radclyffe Hall, who wrote The Well of Loneliness and was known as “John” to her – which is the pronoun she used – friends.

Harry Benjamin asserted that with Type Six “true” transsexuals “psychological guidance or psychotherapy [is indicated] for symptomatic relief only,” but he was writing at a time when virtually all psychotherapy in the United States was Freudian psychoanalysis. I was in Freudian analysis while he was writing The Transsexual Phenomenon, and though I did not know Benjamin I have worked with some of his former patients, and I expect that in that time and place, like everyone else, he had to assume that the purpose of psychotherapy was to effect a “cure” from the transgender identity “neurosis” that would, if successful, excise the desire to be a woman from the morphological man, or the desire to be a man from the morphological woman among FTMs. In that context he saw psychotherapy as virtually useless for treating transgender identities, and in that context I would say he was right, just as Freudian psychoanalysis proved useless for “curing” homosexualities.

But, like other interventions for people we now call “gender dysphoric,” psychotherapy has come a long way in 35 years. Just as gender and transgender identity turn out to be broader matters than even Benjamin could imagine in 1966, so the means and ends of psychotherapy have evolved from the time when psychiatrists alleged that overbearing mothers and absent fathers made men gay, or when Robert Stoller could assert of female-to-male transgender identity that “a hint too much father and too little mother masculinizes girls.” (Stoller, 1985)

A dozen MTFs and another handful of FTMs is not remotely the extent of San Francisco’s transgendered population, of course, nor are such “true” transsexuals of “high intensity” representative of my transgender practice or the transgender practices of any of the therapists I know. Far more common in my experience is the broad range of people for whom concepts like “male” or “female,” “man” or “woman,” “masculine” or “feminine” are insufficient and/or inaccurate.

“Gender dysphoria” is a useful clinical term in a binary society that demands that each person be A or B and live permanently in an absolute condition, black or white, gay or straight, male or female. But in addition to pre-ops, post-ops, non-ops, drag queens, cross-dressers, drag kings, and passing women, I have also known people with intersex conditions, female-bodied people who want to live as men but don’t want hormones, male-bodied people who just want hormones – such as she-males and male-females who take long-term, low doses of hormones (1-2 mg estres) as if they were on post-op maintenance – and male-bodied, female-identified people who just want orchiectomies, as well as third gender people who specifically self-define as two-spirits without regard to Jungian typology. For people who stand between two options, waver among several, or feel themselves to be living across a spectrum that embraces many choices simultaneously: for people for whom making such an either/or choice is to lie to themselves about their own identities, the label implies a pathology that may be partly, largely, or wholly a consequence of knowing something true our society cannot see; in clinical terms it implies a pathology that may be partly, largely, or wholly iatrogenic.

Coming Out Trans: Clinical Issues

I do not think anyone in American psychology can seriously doubt any longer that some people have identity feelings that cross what we call gender boundaries. But whether people who cross those lines are necessarily “gender dysphoric,” or whether that phrase signifies, sometimes, something like a culture-bound syndrome of our own time and place that we have not identified as such because we cannot recognize it, the way a fish, presumably, cannot recognize water: nonetheless, the effects of a gender dysphoria diagnosis on individuals in our culture is very substantial indeed.

If I live in a society that believes only A and B exist, that they are mutually exclusive opposites rather than bipolar complementarities, and that they are absolutes, static and changeless; and if I nonetheless feel I am A despite appearing to be B, or feel I am both A and B, or sometimes A and sometimes B, or neither A nor B, or A, B, and C, or only C, or C, D, and E; and if my society’s designated shamans – that’s you and me, doctor – diagnose my feelings as a mental disorder: well then, I can hardly expect to live a life without the problems that result from being fundamentally misunderstood.

Based on his work in the gender identity clinic at Case Western Reserve University, where he saw some 200 self-identified female-to-male transsexuals by about 1980 6 , Leslie Lothstein (1983) was adamant that most FTMs had borderline personality structures. But the descriptions he provided of his clients’ behaviors and personality traits could also be applied to people whose identities have been systematically denied, and who have been made a little frantic by having drummed into them year after year that they were not who they knew themselves to be. After a lifetime of such treatment, someone’s personality would have to be remarkably strong not to become disordered.

In addition to the enormous emotional and social difficulties inherent in simply being human; and the further difficulties that result from having one’s identity denied; and the additional problems imposed by being an outlaw and outsider by fiat and not by choice – by who s/he is, rather than by what s/he does – many transgendered people may well develop some emotional problems that we might genuinely call Adjustment Disorders with Mixed Disturbance of Emotions and Conduct: a DSM-IV diagnosis that I have been told, incidentally, some insurance companies may read as a clinical attempt to use a reimbursable code for the usually unreimbursable “borderline personality disorder.”

If personality disorders sometimes seem to come with the territory of identity denial, anxiety might well accompany the conflict and confusion of living with a secret you cannot tell anyone, whether on the playground, at home, at work, or in bed. Social issues from lying to agoraphobia to drug abuse to outraged or despairing actings-out might come to feel like expedient and salutary responses to a world that denies you in a very fundamental way. And especially since the desire to transition may sometimes wax and wane for people made unsure of who they are by such unrelenting conflicts, depression is even a likely concomitant of having been told all your life that you are not who you have known yourself to be.

If, in addition, in the words of Oscar Hammerstein II (1949), you have been “properly taught before it’s too late, before you are six or seven or eight, to hate all the people your relatives hate,” you may feel ego-dystonic about your own transgendered status, about your own identity, and about your self. Internalized transphobia, including the shame, rage, and incipient suicidality that frequently accompany self-loathing, has a parallel with which at least some therapists in the GLB communities are all too familiar.

Some transpeople feel sure of their courses even before they begin, and time proves some of them right. But others really cannot make presumptions about where their journeys will take them. As it appears to us through the lenses of sex, gender, and orientation, the fluidity of identity itself is occasionally felt over time even among ostensible Kinsey sixes and zeros; it may confuse or frighten people who are insecure in their own identities, showing up, for example, as that homosexual panic I mentioned earlier that leads some straight men to think all gay men want to fuck them. But the changes wrought by exogenous hormones, the effects of new forms of self-talk, and the social challenges presented by full- or part-time cross-living, particularly in the early stages of transition or exploration, are not always what anyone expected, and they can compound the special difficulties encountered by transpeople.

I do not mean to conflate the extraordinary confusions in living that some transpeople experience with transitions sought or even made in denial of homosexuality, nor with intersex or other kinds of third-gender concerns. But in addition to the other non-dichotomous options I mentioned earlier – non-ops, she-males, passing women, and so forth – therapists working in these communities have to be aware of related issues that mimic, partake of, or co-exist with the more formally delineated transgender experience. It is important not only because at present gatekeeping is still one of our tasks, for better or worse, but because as gatekeepers we are charged with knowing about psychological and sexological options our clients may have reason to stay blind to.

One example that can arise in a practice like mine, that is specifically open to alternate sex and gender concerns, is the fetishistic cross-dresser who has transsexual fantasies. In a self-encounter that accords fairly well with Ray Blanchard’s and Anne Lawrence’s notions of autogynephilia, if I am such a man I may fall more or less in love with the visual or mental image of myself as a woman. I like to see and feel myself dressed up, and perhaps the brain chemicals released as a consequence of the pleasure I feel at the sight or thought of myself dressed up also make me feel good. I feel so good that I get the idea that I should live this way all the time: that I should be a woman, or that I am a woman, and hence that I am transsexual, and I set out in quest of transformation.

In order to be successful in my quest I will need therapists’ letters of referral, if only because most of the reputable plastic surgeons who perform sex reassignment surgery know about the HBIGDA Standards of Care and want to safeguard themselves against the possibilities of lawsuits by dissatisfied customers, so sooner or later I will show up on your doorstep. But if my alleged transsexualism is really fantastic and you refer me to surgery and I go through with it – if I am a man who incorrectly believes myself to be a transsexual woman and I am successful in my quest for surgery – I will probably be unhappy after the fact. Indeed, I am one of the people the HBIGDA Standards of Care was originally intended to protect. Fortunately, as my therapist, you note that I have sustained my womanly image of myself particularly as a sexual fantasy; that it is arousing to me as a major, the major, or the only way I get excited; and that its fascination diminishes virtually as soon as I have masturbated or had some other form of sexual release. This set of facts is usually sufficient to at least consider a differential diagnosis from other forms of transgendered experience.

In my experience, male fetishistic cross-dressers are almost always heterosexual or predominantly heterosexual, and their behavior is commonly, though not always, expressed in complete or relative privacy. This kind of cross-dressing is not the same as drag, which is often a very public display in the gay community. Part of the difference pertains to our earlier discussion about the similarities between the gay and trans experiences. In the heterosexual world shame ordinarily attaches to male fantasies of being female or expressing femininity, whereas drag has lightened up the play around sex since long before drag queens started the Stonewall rebellion. In addition, where straight men sometimes have to cross-dress in order to access their own “feminine” feelings, drag, as Robert Hopcke observes, has historically allowed “gay men to take part in the persona-identification dynamic that is so much a part of collective gay experience and seize it, use it, and transform it in a way that shatters personal and collective assumptions about what it means to be a man or a woman.” (Hopcke, 1995, p. 140).

Coming Out Trans: Specifically Gay-Related Clinical Issues

There are ways in which living and coming out trans are related to living and coming out GLB, and there are ways in which coming out trans is utterly different than coming out gay. But someone who is gay and trans has to traverse both spaces.

But what does it mean to be gay and trans? For that matter, what does it mean to be trans and straight? Is an MTF who is oriented toward women a heterosexual before transition and lesbian after? Was she always “she” and therefore always lesbian even when wearing a male body? Is she always “he” and therefore heterosexual even when wearing a female body? What if her genes and chromosomes don’t match her personal identity, social identity, or body? Which body – the one before or the one after? What do sex and gender mean for the leatherdyke who transitions and becomes a gay leatherman? What can the butch woman do who feels just one step away from being FTM, but is riven with grief at the prospect of losing not just her personal identity and partner, but her community and community identity as well? The prospect of such a loss is very real, and frequently attended by a grievous bout of mourning that has little social sanction. Somewhere along the line most transpeople come to terms, however fortunate or bitter, with the loss or prospective loss of families, friends, jobs, and social places in the wider world. But for someone who has found a home and even shelter in the gay communities, the further loss of this social identity can be like a safety net vanishing along with hope.

Very often gay people put transpeople down as if their struggles are unrelated. Sometimes this is a kind of self-esteem issue, obliquely reflecting an internalized homophobia that demands identifying someone “lower” on the totem pole of social acceptance. Some gay men really don’t like or trust women, and a man who has been a woman in any way may find himself shunned, or derided in their company. Some lesbians who have worked mightily to overcome narrow social definitions of femininity become incensed by what they see as the pretensions of transwomen who deliberately embrace exactly those cultural notions, seeking to learn to walk, for instance, with what is a structurally female swing to the hips; to talk with traditional if socially imposed female inflections and tone; to take up “womanly” pursuits; to study assiduously the proper ways to put on make-up or wear heels, hose, and lingerie; and even deliberately to defer to men, however politically incorrect these behaviors may seem to their genetic “sisters.”

Transwomen may indeed feel that genetic women are their “sisters” in spiritual as well as political and sexual ways, as the late-lamented magazine TransSisters showed; but genetic women do not always reciprocate those feelings. Just as some genetic men reject transmen for having been what they once were at least in body, so some genetic women believe that a transwoman can never really be a woman. This was the Womyn Born Womyn Only position that prevailed at the 1991 Michigan Wymyn’s Music Festival, where Nancy Burkhalter was discovered, confronted, outed, and ousted. As a transsexual woman she had believed herself an appropriate participant in the women-only event she had attended without incident the previous year, but in the eyes of some of the event’s organizers she was a male who had gone to prodigious lengths to infiltrate the sanctity of wymyn’s space, and in effect proved Janet Raymond’s contention that men will stop at nothing to take over anything that belongs to women (Raymond, 1979).

Discrimination and prejudice – pre-judging – affect us all, sometimes in ways we would not have anticipated. In several cities GLB hopes for a supportive alliance with racially discriminated minorities have foundered because the parallels of ostracism that seemed obvious to one group did not even seem similar to the other, while discriminations that seemed endemic to the second group seemed barely relevant to the first. Genuine differences between different groups’ interests cannot always be resolved. These divides were especially strained for gay racial minority members in ways that reflect strains that sometimes arise between the gay and trans communities: no matter how it pains and grieves us to choose our places among them – or to be or not to be chosen by them – we all have multiple identity affiliations, and we all, always, have priorities among them.

Does She or Doesn’t She? Is There Sex After Transition?

Certainly sex plays an important role in many – dare I say, most? – gay and bi male communities, and it is not inconsequential in the lesbian communities with which I am acquainted. It is important to our identities, it is a mode of self-expression, it is politically charged, it is a spiritual avenue, it is a way we are intimate with others, and it is even, simply, a matter of pleasure for most of us. Yet, sex is often a difficult topic for non-trans people to discuss, and it may be considerably more problematic for transpeople, especially for those who do transition.

Sex is one area that provokes discrimination, and at the gay-trans nexus it is not always easy to take sides. How would you feel, as a gay man seeking a hot or a loving time among men, if you encountered a gay FTM at the baths or a soirée? or, as a lesbian seeking the safety of strictly women’s company, if you met a lesbian MTF at a women’s spa or at the Michigan Wymyn’s Music Festival? If you would be at all uncomfortable, where would you prefer this other person go, who is, remember, fully as uncomfortable as you are, and in many of the same ways, in intimate space among differently gendered folks.

Social issues apart, full sexual expression decreases markedly for many MTFs who begin hormones, and more substantially after surgery; by report, some transwomen lose even the desire for sex. While a few transwomen were fully sexually active as men, and it is important to address the prospective change or even loss of that part of their future lives before they embark on medical transition, a certain number of transwomen never did feel especially sexual in their male bodies anyway, and don’t feel transition costs them very much in this regard. Still others, who felt sexual prior to transition, were nonetheless never comfortable being sexual as men, with male equipment, and some of them feel somewhat liberated when they are able to become sexual as women with female equipment.

Unfortunately, not all female equipment is easily created, and I am not here referring to the uterus and ovaries. Problematic as FTM phalloplasty famously is, MTF genital surgery is also imperfect. One of its little-spoken secrets as of this writing is that relatively few post-surgical transwomen appear to enjoy genital orgasm, and many may not have the equipment to do so. The genetic female clitoris has as many nerve endings as its considerably larger male counterpart, the penis, and it has only one purpose in all of creation, which is to give pleasure to the body with which it comes. A successfully operating clitoris is not guaranteed with MTF sex reassignment surgery, also sometimes called gender confirmation surgery, and many transwomen with whom I have spoken – including some who enjoy other aspects of sex enormously – did not get one. While there is nothing we can do directly about this circumstance as therapists, we can anticipate the problem and discuss it with our clients in advance, and if necessary we can listen about it afterwards, when we may be helping people through yet another grieving process they had not anticipated.

There is also evidence that some, not all, transwomen who do not become sexually active within a few years after surgery may simply cease to pay much attention to sex, both in specifically erogenous terms and in the larger sense of Eros. If they feel that neither sex nor erotic intimacy is going to be part of their lives again they may become lax about self-care in general, including dress and other features of their presentation. If that laxity is a sign of depression, if it accompanies a despair about ever being seen as who she feels herself to be, the transwoman may cease to dilate; in some instances her neo-vagina may begin to close up. Insofar as the physical shutting-down process reflects a psychological shutting down, the former can sometimes be successfully addressed by addressing the latter.

If, as it appears, MTFs have less sex on balance than they may have done before, or than genetic women ordinarily do, a significant proportion of FTMs apparently have more sex than they ever had before, once their hormones start to kick in. The classic comparison between new FTMs and genetic male adolescents includes many forms of interimly desocialized behaviors regarding bathing, grooming, dressing, and social activities, including the practice of safer sex, and derives from just this encounter. In my experience it is often but not remotely always true: I have also known FTMs who came out as highly civilized and even courtly gentlemen, and others who just came out as men without much adolescent ado. The individual’s pre-transition levels of maturity may quite reasonably affect his behaviors during and after transition. But I have only occasionally heard that a transman’s interest in sex did not increase when he began taking exogenous testosterone, and I have never yet heard of someone’s interest decreasing.

4. CONCLUSION: WHAT TO DO

The Legitimacy of Intervention

There is a long record of gender variation throughout history and across cultures, but most of what’s new today lies with medicine – with endocrinology, surgery, and the less visible biology of genotypes. Although we’ve begun to get a sense of gender’s variety and range since Magnus Hirschfeld’s first investigations a century ago, the whole experience of gender as identity, perception, role, and inter- and intra-personal experience distinct from morphological sex remains poorly understood at our stage of the human experiment. From where I stand we hardly have the right to presume to say what someone else can or cannot, or should or should not, do with her or his own body or life; but by educating ourselves we can help people prepare for and live with the realities that aren’t fantasies.

There has been a great deal of discussion in the communities over the years about whether transgender identities should be classified as mental disorders, and whether they are biological, psychological, or spiritual in origin; consequently, there has been a great deal of discussion about whether their examination and treatment should be paid for by medical insurance. Especially for people who seek medical assistance to resolve discrepancies between their bodies and their minds, this discussion also helps drive the question of whether interventions such as hormones and surgery should be provided on demand. And the medical questions fuel psychological ones.

For one “class” of transgendered people, most of whom in my experience are white, educated, genetic males who are familiar with the social and political protocols of our time and who can afford the interventions, this approach – medical intervention, including surgery, on demand – makes almost obvious sense, even though they are often the people who have most to lose in transition. They are accustomed to getting what they want, they are articulate in asserting their rights to have it, and they have the resources to fight for it.

For many others, however, who have scant outer or inner resources, who have fallen into personal disrepair because they cannot or do not know how to navigate the landscape of our social structures, and who have so little to lose they can’t afford to lose anything, interventions on demand may court even greater disasters than those they already live with. If you can’t afford hormones, for example, can’t remember where to procure them or when to take them, and sometimes even have no place to store them because you have no place to live, does it help or harm you to be introduced to a physical and bio-chemical regimen that requires regular attention and that lasts a lifetime? Questions of personal responsibility and personal capability, like questions of individual rights and societal needs, impassion this entire investigation that must involve you and me, who are required every day to pass judgments on feelings, thoughts, beliefs, attitudes, and behaviors in ways that may create pathologies by fiat concerning identity issues that may otherwise not be pathological at all.

A few pages ago I raised the possibility that each of us might encounter a transperson in one of our personal, intimate environments, and wondered where else we might propose that person go to satisfy the same needs for intimacy or gratification we were seeking to address, particularly if we were personally uncomfortable with that person’s presence.

We hear and speak a good deal in our trainings, consultation groups, and maybe in our private supervisions about transference, and we are advised – quite rightly, I believe – to attend to it whether or not we are planning to analyze the transference in the classic Freudian mode. But even in school, and especially once we’re out in the professional world, we hear precious little about our own parallel experiences in the consulting room. Yet, countertransference cannot but come up for all of us, and where we have not worked through our own issues about gender or identity it may well arise with our transgendered or gender questioning clients.

After you and I have read the books and written the papers and gone home, our clients are out there living the life. It is valuable to visit and revisit our own transgender issues, not only for our benefits, but also to ensure that we are honest in our work. Staying psychologically clean through self-examination, as we can in our individual and group therapies and supervisions, is one form of harm reduction we can easily offer our clients. It is the sort of ready opportunity for self-reflection any psychotherapist should embrace eagerly, and it is a way we can help keep other people safe from us where we, too, are only human.

PLISSIT

Another harm reduction strategy is embodied in the PLISSIT model of intervention developed by Jack Annon. In its very structure, PLISSIT recognizes that not every person coming in my door wants the same thing; it further asserts that most people want less rather than more, and few want all, of what is available through the psychotherapeutic process.

The first thing nearly every client wants from me is Permission to be him- or herself. I don’t mean s/he has not wrestled with and resolved this matter – maybe yes and maybe no – but that s/he needs permission to be him- or herself in my life, in my space, and in any process we are going to share. Another way to understand permission in this regard is to see it as Rogerian unconditional positive regard, or as empathy. Permission does not mean encouragement any more than it means discouragement; it neither applauds nor condemns: it simply accepts: permission is acceptance without anything added or taken away.

Most clients who feel accepted – who have permission to be themselves with me – next want some forms of Limited Information. One person may want information about his process, another may want information about resources, a third may want information about my training and background. But the underlying quest at this point is for information about where we two might meet, where we might go together as client and therapist, and how we might go there. Often the information is requested and provided implicitly, underneath the conversation that might be transcribed from a voice recording of what we seem to say; and nearly always the client does not articulate what s/he is trying to find out. Yet, if I fail to read the underlying questions, our alliance will likely be short-lived. The client who asks me for resources can surely find them elsewhere, and may chiefly want only to know, for instance, if I have the depth of relevant knowledge that knowing about those resources attests. The client who asks about my training may be confirming or questioning feelings of permission, or testing my boundaries. The client who asks about my process may want a model s/he might adapt personally.

When my client is satisfied that we can build an alliance, and when I am similarly satisfied, s/he may want Specific Suggestions about what to do next. Asking for such suggestions, whether overtly or tacitly, does not imply s/he doesn’t know already. It may mean s/he is asking me to demonstrate the way I work, to show how we can work together.

Whether s/he and I will ever do Intensive Therapy together, which may or may not be what s/he came to see me for, we will certainly not do it unless we reach this point. For my transgendered clients, this is the point at which I become something different than a gatekeeper, a source of referral letters, a fount of information or knowledge or advice, an ear, or a paid friend. This is the point at which I become – if I am going to become one at all with a particular client – a psychotherapist.

The End

For some of my transgendered clients, a cross-gender personality may take over the life in an entirely appropriate or inappropriate manner. For others, important as the transgendered aspect may be, such a step may be either impossible or undesirable: while the transgendered component may be quite as real as it is in the first group’s lives, that proportion of the person in the second composite is not so great that it can effectively command the life, and so it can almost only live interiorly or come out occasionally. For still others the transgendered component becomes less important over time and with work, steps back out of the light, and perhaps even – functionally – disappears as other questions are resolved. It is never my job to decide how my client should live his life, of course, but it is always my job to help a person come to her own choices.

It helps me, sometimes, to remember that transsexualism or gender identity variation of any sort is not necessarily or exclusively a psychological or even a sociological expression: recent research suggests that at least sometimes and maybe often, gender identities that differ from a body’s apparent sex may be consequences of genetics or other biological factors. But even if transgender identity questions always and only arise because of biological factors, there is a great deal of understanding and healing many transgendered persons need in order to live in satisfactory, satisfying, and fulfilling ways. In the course of this work it is usually helpful and often essential to have a knowledgeable and compassionate witness who can facilitate the process. And that, I think, is the least of what I am there for.

1. If to you “yahoo” means only a drink or an internet company, read Jonathan Swift’s Gulliver’s Travels.

2. Although Gibson’s report was expressly not a research paper, and has been disputed by various fundamentalist sources (e.g., LaBarbera, 1996), it has been supported by other studies that were researched. For example, Gary Remafedi, a pediatrician, Assistant Professor of Pediatrics at the University of Minnesota, and author of Death by Denial: Studies of Attempted and Completed Suicide in Gay and Lesbian and Bisexual Youth, found in a 1991 study of 150 gay and lesbian youths in Minneapolis, more than 30% said they had attempted suicide at least once as a teenager. “The youths who are at the greatest risk for suicide are the ones who are least likely to reveal their sexual orientation to anyone. Suicide may be a way of making sure that no one ever knows. It’s homophobia that’s killing these kids.” Remafedi not only confirmed this 30% rate among gay and bisexual youth: he also found that “young men with more feminine gender role characteristics” and those who recognized their same-sex orientation at an early age and acted on those sexual feelings seemed to face the highest risk of self-destructive behavior. (emphasis added). A more recent sibling study found that gay and lesbian people had higher rates of self-injury, suicidal thoughts, and suicide attempts than their heterosexual counterparts, and were more likely to have sought psychotherapy, used psychiatric medications, and spent time in psychiatric hospitals. The authors speculate that the higher rates were due to the strain of belonging to a disfavored minority, and also, possibly, to a greater willingness to acknowledge and report emotional challenges. Although in this study bisexuals differed from lesbians and gay men only in having higher rates of self-injury, other research has found that people who self-define as bisexual are especially vulnerable to psychiatric symptoms. (Balsam, et al, 2005)

3. Except, possibly, in some cases of severe, persistent abuse that begins very early in childhood, such as those in which the abused child is forced or coerced to deny what happened to him.

4. Transsexuals may be at higher risk than homosexuals and much higher risk than the general population to suicidal behavior. Fifty-three percent of transsexuals surveyed had made suicide attempts (Huxdly, J., and Brandon, S., 1981).

5. Richard Green, in The Sissy Boy Syndrome, found on the basis of a small sample that gender dysphoric boys are more likely to be gay than trans as adults. There has been a presumption that the same result will hold for a larger sample, and that it will also hold females as well as for males, but I know of no relevant research. Harry Benjamin’s profile of the “primary” transsexual, supported by Richard Docter, is the gender dysphoric child who grows up attracted to what appears to be same-sex relationships but actually remains gender dysphoric and so sees him- or herself as heterosexual where other people see the individual as gay or lesbian. In this schema, the secondary transsexual comes to the realization of gender dysphoria later in life, generally in adulthood.

6. Wait! He saw 200 FTMs? In Cleveland? In the 1970s? Even though, as Rebecca Auge, Ph.D. points out, Case Western was the clinic for a catchment area that extended across several states, the number is extraordinary for the times, when there was hardly even any MTF community and no FTM community at all. Indeed, Lothstein’s was the first book ever published about FTM people.

Fraser, L. (1991). Classification, assessment and management of gender identity disorders in the adult male: a manual for counselors. Unpublished doctoral dissertation, School of Education, University of San Francisco, San Francisco, CA

Green, R. (1987). The sissy boy syndrome and the development of homosexuality. New Haven: Yale University Press

Hammerstein, O. (1949). South Pacific (1958). Written by Oscar Hammerstein and Joshua Logan, music by Richard Rodgers, directed by Joshua Logan, from Tales of the South Pacific by James Michener. 20 th Century Fox et al